109-Another High Growth Industry Comes Under Assault

For many years now, large employers and governments have contracted with pharmacy benefit managers (PBMs) to provide and administer drug coverage for their employees. In turn, the PBMs tell the employers that they will pass on a good part of their purchasing economies to save the employers’ cost. This approach has worked well for the PBMs for years. They have been highly profitable businesses.

These high profits have attracted the attention of a new scary competitor, Wal-Mart (see “Video #3: Predicting the Direction of Margins” on StrategyStreet.com). Wal-Mart is offering businesses low-priced drugs if they sign up to have their employees purchase directly from Wal-Mart’s network of in-store pharmacies. Wal-Mart will offer these businesses a fixed mark-up over its cost for the drugs. While Wal-Mart will not reveal the cost of its purchases, it will have a third party verify the mark-up, thus guaranteeing the business of its deal.

Wal-Mart benefits in two ways with this new business program. It guarantees a profit on each sale with its cost plus pricing. It also draws more customers into its stores where it has a chance to sell them other products. This Wal-Mart product innovation follows on the heels of a similar consumer program they introduced some time ago. In this latter program, Wal-Mart introduced a $4 per subscription generic drug program for consumers. This drug program forced the entire retail drug industry to offer discount plans and it lowered the cost of drugs for consumers. Wal-Mart is a discounter, a Predator type of Price Leader (See “Video #21: Definition of Price Leaders” on StrategyStreet.com).

Will it succeed with this new business-oriented program? A discounter is likely to succeed if it can attract the largest customers in the market place. We call these Very Large customers. Wal-Mart has already attracted one of those very large customers in Caterpillar Company. Caterpillar has purchased drug coverage for 70M employees and their dependents through Wal-Mart. This customer has been so pleased with its savings in the drug benefit program that it has waived co-payments on generic prescriptions that its employees purchase from Wal-Mart. This, of course, makes the Wal-Mart program even more attractive to the employee because it is cheaper than any other alternative available. The forecast? Costs down for businesses. Lower profits and growth for PBMs. (See the Symptom and Implication, “The industry leaders are losing share” on StrategyStreet.com.)

Posted 6/1/09


PBMs serve as intermediaries between drug manufacturers, health insurance plans and pharmacies to negotiate prescription drug prices.  While in 2022 there were nearly 70 different PBMs, the industry is highly concentrated. The top 4 competitors own 85% of the market.  The top 6 PBM’s handled more than 95% of total US equivalent prescription claims.  5 of the 6 largest PBM’s are part of large vertically integrated organizations that combine insurers, PBM’s, specialty pharmacies and healthcare providers.

This vertical integration made it difficult for Walmart to maintain an independent PBM. Instead, the company formed a partnership with the largest PBM, CVS Caremark.

The relationship between a PBM and its customer base can lead to mistrust. There is little transparency in pricing, as you would expect in a consolidated industry. In late 2021, a nonprofit coalition of nearly 40 private employers launched a new company that would offer pharmacy benefit management services for employers. This coalition includes major retailers such as Walmart and Costco along with major corporations such as Boeing and Microsoft. This new company provides much more transparency to the pricing of drugs, especially of specialty drugs, which have taken an increasing share of the total drug spend. The new company offers a “clearinghouse” pricing model which provides fixed unit costs for drugs up front to all clients. This is the first significant PBM to offer this type of pricing.  Another major advantage of the new PBM for employers is that they will own their own data and have information and tools in clinical resources dedicated exclusively to their unique needs and patient populations.

The leading PBMs are losing the trust of many of the largest customers of the industry. These customers do not trust industry pricing, which is likely high. The industry is ripe for hostility. See more HERE.




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